What happens when intravenous (IV) vancomycin infiltrates?

Vancomycin Infiltration: Consequences and Management

When IV vancomycin infiltrates, it can cause tissue damage ranging from local inflammation to severe necrosis requiring debridement due to its vesicant properties and acidic pH (2.5-4.5). Immediate recognition and management are essential to prevent long-term complications.

Tissue Effects of Vancomycin Infiltration

Vancomycin infiltration can cause:

• Local inflammation and pain at the infiltration site
• Erythema and swelling
• Blistering of the skin
• Tissue necrosis in severe cases 1
• Subcutaneous calcifications (rare complication) 1
• Dermatitis that may mimic bullous cellulitis 2

The FDA label specifically notes: "Vancomycin hydrochloride for injection is irritating to tissue and must be given by a secure IV route of administration. Pain, tenderness, and necrosis occur with inadvertent extravasation" 3.

Risk Factors for Infiltration

• Peripheral IV catheters (higher risk than central lines)
• Poor cannulation technique
• Prolonged infusion time
• Higher vancomycin concentrations (>10mg/ml) 1
• Patient factors (fragile veins, agitation)
• Inadequate monitoring of IV site

Management Protocol for Vancomycin Infiltration

Immediate Actions:

1. Stop the infusion immediately
2. Disconnect the IV tubing but leave the catheter in place
3. Attempt to aspirate any residual medication through the catheter
4. Remove the catheter after aspiration attempt
5. Elevate the affected limb

Local Treatment:

• Apply cold compresses for the first 24-48 hours to reduce inflammation
• After 48 hours, switch to warm compresses to increase circulation
• Monitor for signs of tissue necrosis or compartment syndrome
• Consider local infiltration with hyaluronidase in severe cases

Follow-up Care:

• Regular assessment of the affected area
• Wound care for any tissue breakdown
• Surgical debridement may be necessary for necrotic tissue 1
• Plastic surgery consultation for extensive tissue damage

Prevention Strategies

1. Proper IV site selection and cannulation technique

2. Appropriate dilution of vancomycin:

   • Dilute to concentrations of 2.5 to 5 g/L 3
   • Never exceed 10 mg/mL concentration 1

3. Proper administration technique:

   • Administer as a 60-minute infusion 3
   • Rotate venous access sites for prolonged therapy 3
   • Consider central venous access for extended therapy

4. Regular monitoring:

   • Frequent visual inspection of IV site
   • Ask patient about pain or burning at IV site
   • Consider technology solutions like bioimpedance monitoring for early detection 4

Special Considerations

• The IDSA guidelines do not mandate central catheter use for vancomycin administration, noting that "mandatory use of a central catheter over a noncentral catheter for OPAT with vancomycin is not necessary" 5.

• Vancomycin's vesicant properties are particularly concerning at higher concentrations, with tissue damage including blistering and necrosis reported at supratherapeutic doses 1.

• The mechanism of tissue damage appears related to vancomycin's acidic pH (2.5-4.5), which directly harms the vascular wall 2.

• In rare cases, vancomycin infiltration has been associated with subcutaneous calcifications, potentially representing a localized form of calciphylaxis 1.

Documentation and Reporting

• Document the infiltration event thoroughly
• Include estimated amount of drug infiltrated
• Photograph the site if possible
• Report as a medication administration incident
• Follow up with the patient to monitor for long-term complications